Evidence synthesis - COVID-19 among Black people in Canada: a scoping review

Abstract Introduction: The COVID-19 pandemic exacerbated health inequities worldwide. Research conducted in Canada shows that Black populations were disproportionately exposed to COVID-19 and more likely than other ethnoracial groups to be infected and hospitalized. This scoping review sought to map out the nature and extent of current research on COVID-19 among Black people in Canada. Methods: Following a five-stage methodological framework for conducting scoping reviews, studies exploring the effects of the COVID-19 pandemic on Black people in Canada, published up to May 2023, were retrieved through a systematic search of seven databases. Of 457 identified records, 124 duplicates and 279 additional records were excluded after title and abstract screening.Of the remaining 54 articles, 39 were excluded after full-text screening; 2 articles were manually picked from the reference lists of the included articles. In total, 17 articles were included in this review. Results: Our review found higher rates of COVID-19 infections and lower rates of COVID-19 screening and vaccine uptake among Black Canadians due to pre-COVID-19 experiences of institutional and structural racism, health inequities and a mistrust of health care professionals that further impeded access to health care. Misinformation about COVID-19 exacerbated mental health issues among Black Canadians. Conclusion: Our findings suggest the need to address social inequities experienced by Black Canadians, particularly those related to unequal access to employment and health care. Collecting race-based data on COVID-19 could inform policy formulation to address racial discrimination in access to health care, quality housing and employment, resolve inequities and improve the health and well-being of Black people in Canada.


Introduction
The World Health Organization declared COVID-19 a global pandemic in March 2020, triggering the adoption of numerous public health measures, including lockdowns, social distancing and the use of facemasks in public places.However, the health risks of COVID-19 infection and public health measures to reduce infection did not affect everyone equally; [1][2][3][4][5] the burden was disproportionately greater for racialized people and those living in lowincome communities. 6][9][10][11][12][13] For every 100 000 Americans, about 26 Black people died from COVID-19 infection, a mortality rate more than twice that of Latino, Asian or White people. 13In the UK, the mortality rate among

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5][16][17] Despite representing only 9.28% of the population of Toronto, Ontario, Canada's largest city, Black people accounted for nearly onequarter of COVID-19 cases in 2020, while White people, who constituted 49.64% of the city's population, represented only 21.7% of cases. 18nada is a common destination for international migrants, with a growing population of Black people from sub-Saharan African and Caribbean nations. 19Black people are the third-largest racialized group in Canada, at 4.3% of the country's total population, after South Asian (7.1%) and Chinese (4.7%) people. 20st of the reasons why the Black population was highly susceptible to and affected by COVID-19 infection are rooted in social determinants of health, such as socioeconomic status, crowded living environments, cultural barriers, racial discrimination, poor access to health care and anti-Black racism. 21In Canada and the USA, systemic racism cuts across all sectors-health care, education and the labour force-a problem that continues to be overlooked in policies. 21,22Because of the extensive emphasis on individual behaviours, rather than tackling the challenges that confront systemically marginalized Black people, 21 the health care system failed to account for numerous inequities, including in education and employment, that tended to expose Black people to high rates of COVID-19 infection and mortality, to the point that racism has been described as "a risk factor for dying from COVID-19." 23r instance, racialized and immigrant populations experienced unequal access to vaccination and high rates of infection and death from COVID-19. 24,258][29][30] Racial inequalities to do with health and environmental factors affect racialized people in a way that left them "more exposed [to] and less protected" from the COVID-19 virus. 8,23,30ta from the USA demonstrate racial disparities in rates of COVID-19 infection and mortality, with Black people among the most disadvantaged. 8,23However, few studies have focussed on COVID-19 among Black Canadians.Given the disproportionate burden of COVID-19 and the distinct risks that Black Canadians face, the purpose of this scoping review was to map out the scope of research on COVID-19 among Black people in Canada.

Methodology
We utilized a scoping review methodology to explore the "extent, range and nature of research activity," 31 explicate what is currently known about COVID-19 among Black Canadians and pinpoint knowledge gaps for future research.We applied Arksey and O'Malley's 31 five-stage methodological framework for conducting scoping reviews: identifying the research question; identifying relevant studies; selecting studies; charting the data; and collating, summarizing and reporting the results.We used the Tricco et al. 32 Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) approach.

Identifying the research question
This review was guided by the following question: "What is the scope and nature of the literature on COVID-19 among Black people in Canada?"

Identifying relevant studies
We identified relevant studies through a systematic search in seven electronic databases: Ovid MEDLINE (Table 1), Elsevier Embase, APA PsycINFO, CABI Global Health, EBSCO CINAHL, Elsevier Scopus and the Wiley Cochrane Library.Our search strategy was derived based on two main concepts: (1) COVID-19 (all variants), and (2) Black people in Canada.

Selecting studies
Our initial search was conducted in January 2022 with no time restrictions.We subsequently updated the search to include all records published to 31 May 2023.A total of 457 records underwent initial screening of titles and abstracts (by AO and JK), and 124 duplicates were excluded.Two authors (AO and JK), working independently, reviewed the abstracts of the remaining 333 articles.Any conflicts during the process of selecting articles were resolved by a third author (DA).
An additional 279 articles were excluded as they did not meet the inclusion criteria (studies focussing on Black people living in Canada and on COVID-19).Of the remaining 54 articles, 39 were excluded after the full-text screening.In total, 17 articles were included in this review.
The selection process is depicted in Figure 1.

Charting the data
Two research team members (AO and JK) conducted the data extraction, which involved charting and sorting the findings of the included studies into key issues and analytical categories related to the impact of COVID-19 on Black people in Canada.The following information was extracted from each of the included articles and recorded on an Excel spreadsheet (version 2007; Microsoft Corp., Redmond, WA, US) designed by the research team: author name(s), year of publication, study purpose/research question, study population, methods, results/findings and comments/ implications (Table 2).A research team member (DA) performed a quality check to ensure completeness and accuracy.

Collating, summarizing and reporting the results
We analyzed quantitative data from numerical summary and qualitative studies using thematic analysis.Drawing on Braun and Clarke, 34 two research team members (AO and JK) read the included articles several times, familiarized themselves with the data, and synthesized and categorized the interpretations of recurring findings into themes.They then open coded the extracted data by going through the fragments of texts, line by line, and assigning labels that best described these fragments.The codes were then compiled into potential themes, all the data relevant to each potential theme were grouped together, and the data were compared across the coded excerpts and the entire dataset.Two other research team members (DA and BS) reviewed the assigned codes and themes.

Ethics approval
This scoping review does not contain any studies with human participants or animals that may have required ethics approval.

Results
A total of 17 empirical studies met our inclusion criteria.Twelve articles used quantitative methodologies (mostly crosssectional study designs), four used qualitative methodologies (mostly explorative) and one used mixed methods.All included articles described the impacts on Black Canadians of, for example, poor accessibility to COVID-19-related health care services, health inequities caused by COVID-19 and the role of systemic discrimination and racism in the creation of these inequities.
Our findings are presented in five themes: low uptake of COVID-19 screening; high rates of COVID-19 infection; low uptake of COVID-19 vaccines; systemic racism and discrimination; and mental health impacts.

Low uptake of COVID-19 screening
Two studies reported on disparities in COVID-19 screening. 35,36In a crosssectional study, Pongou et al. 36 found that the prevalence of being tested for COVID-19 across reported COVID-19 symptoms was far lower among Black Canadians (8.46%) than among those who were White (17.30%),mixed race/ethnicity (28.41%) or from another ethnoracial group (27.37%), although the differences were not statistically significant.
In a 2021 qualitative study, local community health centre leaders who serve communities with large populations of racialized people within the Greater Toronto Area expressed concerns that individuals' reluctance to get tested for COVID-19 were due to misconceptions that the test is painful and that people can get infected with COVID-19 from screening. 35The study also noted discrepancies in resource allocation within the health care system.For instance, mobile testing was made available in nonracialized neighbourhoods sooner than in poorer and racialized areas with worse access to health care. 35

High rates of COVID-19 infection among Black Canadians
7][38][39] A quantitative study indicated that higher numbers of COVID-19 cases are associated with socioeconomic factors such as race and housing.For instance, of all marginalized groups in Montréal, Quebec, the strongest relationship with positive COVID-19 cases occurred among those living in overcrowded housing and in boroughs with high proportions of Black people. 37o qualitative studies reported on the greater risks for Black people of contracting COVID-19 as a result of overrepresentation in frontline work and low-income communities. 37,38Using COVID-19 counts and tabular census data, Choi et al. 39 showed that there were relatively higher numbers of infections in communities with larger proportions of Black and lowincome residents across Canada.These vulnerabilities were created by poverty, overcrowded living environments, predominance of frontline work and existing health care inequities. 36,37

Low uptake of COVID-19 vaccines
][42][43][44][45] A quantitative study exploring COVID-19 vaccine coverage among people experiencing homelessness in Toronto found that about 80.4% of participants received at least one dose of a COVID-19 vaccine and 63% had received two or more doses; however, Black participants were consistently found to have greater vaccine hesitancy, likely because of distrust in health care providers, perceived commercial gains for vaccine manufacturers, perception of vaccine risks, and lack of paid sick or vaccination leave. 41o qualitative studies reported that the spread of disinformation and misinformation about COVID-19 within Black communities in Canada during the early part of the pandemic affected people's understanding of the risk of the consequences of COVID-19 infection, which propagated vaccine hesitancy. 38,40Gerretsen et al. 42 conducted a quantitative web-based survey in Canada and the USA to assess variations in vaccine hesitancy; the authors reported that despite perceiving COVID-19      Two quantitative study findings reported lower vaccination rates and higher vaccine mistrust scores among Black individuals as a result of their experiences of major racial discrimination in the health care system. 43,44In addition, a quantitative study of vaccine willingness found that African, Caribbean and Black individuals at greater risk of infection with COVID-19 were more willing to get vaccinated, and those who had received their first dose of the COVID-19 vaccine were more willing to receive upcoming doses. 45

Systemic racism and discrimination
7][48][49] The significant link between police cruelty towards Black people in Canada, increased rates of COVID-19 in the Black population and the correlation of lower socioeconomic status, lower level of education and lower-paying employment with great risk of exposure to COVID-19, serves as a symbol of the continuing and historical racism experienced by Black people. 46he underlying systemic racism and related inequities resulted in mistrust of health care providers. 40Miconi et al. 47 conducted a mixed study on risk of exposure to COVID-19 and the relation to discrimination and stigma associated with mental health findings.The authors reported that Black, Arab and South Asian participants had higher prevalence of infection, while Black and Asian participants disclosing greater COVID-19-related discrimination and stigma as a result of their employment, for example, as frontline workers. 47e quantitative study conducted by Noble et al. 49 revealed that systemic racism and the COVID-19 pandemic exacerbated mental distress among Black youth experiencing homelessness in Toronto, with barriers to securing employment and landlords' racial discrimination making it difficult to obtain accommodation.
A qualitative study revealed that there was insufficient information on the type of training frontline health workers and administrators require when providing services to African, Caribbean and Black communities. 48No concrete evidence is available to enhance strategies to ensure health equity and mitigate the impact of COVID-19 in African, Caribbean and Black communities.

Mental health impacts
Four studies reported on mental health impacts of the COVID-19 pandemic on Black people in Canada. 38,47,50,51A qualitative study found that online misinformation about COVID-19 aggravated mental health issues among Black Canadians and resulted in fear of and anger about mandatory vaccine orders. 38Some Black community members were afraid of being stigmatized whether they received or declined the COVID-19 vaccine, which amplified their anxiety about COVID-19 and prevented them from getting vaccinated or promoting vaccination. 38 their quantitative study on eye care professionals' mental health risk factors during the COVID-19 pandemic, Pang et al. 50reported poor emotional health among Black and Asian optometrists, noting that they were more prone to mental distress and elevated symptoms of depression and anxiety than other ethnoracial groups.Miconi et al. 47  Two studies in this scoping review showed that early measures to control the spread of COVID-19 (e.g.screening) were not effectively implemented in the areas where most Black people resided, which increased residents' risk of infection. 35,36he COVID-19 mortality rate among Black people living in low-income areas was 3.5 times higher than in nonracialized and non-Indigenous populations living in lowincome areas. 52Further, Black people have been at greater risk of hospitalization for and dying from COVID-19 due to inadequate access to health care providers and services. 53,54Other factors that contribute to the high rates of COVID-19 infection among Black people include poverty, poor and overcrowded living conditions, and employment in precarious frontline work. 55,56ommunities in Canada with larger proportions of Black and racialized populations had higher rates of COVID-19 infection and death. 55,56][57] Other studies conducted in Edmonton, Alberta, 58 and Montréal, Quebec, 59 also revealed that Black Canadians were more likely to experience negative socioeconomic effects of the COVID-19 pandemic. 58,59These results speak to the need for fair distribution of COVID-19 preventive and treatment services.
Several studies 38,[40][41][42]44,45 in our scoping review described the low uptake of COVID-19 vaccines among Black Canadians. Vaccie hesitancy, recognized as a serious threat to public health, is significant among Black people.Some of the factors leading to vaccine hesitancy among Black Canadians are anti-Black racism in health care, distrust of the health care system and the failure to prioritize Black communities during vaccine rollouts.40,42 This is consistent with the findings of a systematic review from Canada 60 and a meta-analysis from the USA.61 Statistics Canada reported that a much lower proportion of the Black population (56.4%) were very or somewhat willing to be vaccinated compared to White (77.7%) and South Asian (82.5%) populations.62 The distrust of COVID-19 vaccines is partly rooted in historical events of medical cruelty and unethical health research carried out on Black people, the perceived precipitous development of the vaccines, and community members' lack of access to adequate information about the safety of the vaccines.[63][64][65] A systematic review found that, given that many factors influence vaccine hesitancy, multicomponent interventions that incorporate intensified communication, culturally inclusive informational materials, community outreach and greater accessibility are the most reliable strategies to address this issue.66 Black people's trust in the COVID-19 vaccine and its acceptance can be achieved by involving trusted community and faith leaders, 67 providing culturally congruent materials and making vaccine information more accessible.68,69 In addition, a change in health policies and programs to garner trust and direct more attention to anti-Black racism will increase vaccine uptake in the Black Canadian community.Employing culturally representative health care personnel to inform Black people in the community can also influence acceptance of COVID-19 vaccine.70 The findings from this scoping review suggest that many Black Canadians had difficulties accessing COVID-19-related health care as a result of racism, systemic bias and socioeconomic vulnerabilities.Black Canadians largely perceive the health care system as racially and culturally alienating, and feel that the medical language and cultural barriers had a negative impact on their health care access; 62 and this was exacerbated at the peak of the COVID-19 pandemic.The pandemic revealed the discrimination and racism that have long resulted in poor emotional, mental and physical health outcomes for African-Americans in the USA, 70 with minority groups tending to receive lower standard of care than White people do, predisposing African-Americans to worse COVID-19 outcomes.71 Black Canadians' relationships with health care personnel have been negatively affected by cultural differences, lack of cultural competence, dependence on the biomedical model and discrimination that has resulted in mistrust.[72][73][74] Culturally sensitive interventions can enhance health care and patient outcomes, 75,76 so it is critical to provide Black Canadians with a range of treatment options that incorporate culturally specific supports.Cultural awareness training for health care workers and employment of more Black health care workers would meaningfully contribute to overcoming cultural barriers to health care for Black people in Canada.
Our scoping review also found that Black Canadians and other minority groups encountered mental health distress during the pandemic. 38,47,50,51Existing discrepancies in mental health among Black people in Canada and African-Americans in the USA were exacerbated during the COVID-19 pandemic. 77,78Numerous factors, such as socioeconomic factors and access to mental health services, are responsible for the discrepancy. 78Resolving misinformation among Black Canadians through reliable sources and adapting tailored, multimodal and culturally intelligent messaging is important.

Strengths and limitations
To the best of our knowledge, this is the first scoping review that focusses on empirical research on the effects of the COVID-19 pandemic on Black people living in Canada.

FIGURE 1 PRISMA
FIGURE 1 PRISMA 2020 flow diagram depicting identification of studies via databases on COVID-19 among Black people in Canada

TABLE 2
8,17,79ll number of studies included (n = 17) demonstrates the lack of research on COVID-19 among Black people in Canada, suggesting the need for more studies.Our review revealed structural barriers, high rates of COVID-19 infections and low uptake of COVID-19 vaccines among Black Canadians, confirming research findings that the COVID-19 pandemic amplified health inequities, generated new barriers to health care, increased mistrust and reduced a sense of belonging among Black people.8,17,79Moreresearchneeds to be conducted to inform policies and programs to address the root causes of inequities.Some of the studies in this scoping review highlight the need to prioritize the equitable allocation of COVID-19 preventive measures and treatment.COVID-19 prevention strategies that are culturally appropriate and specific should also be made available and accessible.More generally, such initiatives should address the existing barriers associated with structural racism, medical distrust, educational inequities and health inequities.Canadian federal and provincial governments should implement strategies geared towards partnerships with Black-led and Black-focussed community groups to appropriately manage COVID-19 vaccine knowledge gaps and associated distrust factors and barriers, as sensitive and safe education implementation will increase vaccine confidence and herd immunity among Black communities to the benefit of society.Finally, collecting race-based data with the aim of resolving inequities and improving the health and well-being of Black people in Canada is essential to inform policies and address racial discrimination and access to health care services, as well as quality housing and employment.